[Insufficient symptom control under long-term treatment with PPI in GERD - fact or fiction?]

Experience With an Innovative Surgical Treatment Option for Gastroesophageal Reflux Disease: Results of 28 Patients in a Retrospective Analysis

Introduction: Standard-of-care gastroesophageal reflux disease (GERD) procedures are associated with adverse events (AEs) (i.e., dysphagia, gas-bloating). RefluxStop has been developed to circumvent these outcomes. This study presents the results of 28 patients managed with RefluxStop in Germany. Methods: Between July 2021 and November 2023, 28 patients with GERD underwent RefluxStop surgery, a novel laparoscopic antireflux procedure. Retrospective chart analysis with patient-informed consent was conducted to determine clinical outcomes, such as GERD Health-Related Quality of Life (GERD-HRQL) score, proton pump inhibitors (PPI) use, symptomatology, patient satisfaction, and perioperative AEs. Results: Baseline characteristics (n = 28): age 47 ± 13.1 years; 67.9% female; body mass index (BMI) 27.3 ± 4.1 kg/m2; 93% PPI use for 5.6 ± 2.7 years; and hiatal hernia in 100% of cases of mean (standard deviation [SD]) size 3.4 (0.8) cm, whereof 35.7% were large hiatal hernia (4-6 cm). At a mean (SD) follow-up of 14.1 (4.7) months, patients experienced 88.6% improvement in median (IQR) total GERD-HRQL score from a baseline of 35 (7.7) to 4 (4.2) at follow-up (P < .05). Preoperative dysphagia (35.7%) resolved completely in all patients (P < .001). The mean (SD) GERD-HRQL heartburn subdomain decreased by 90.6% from a baseline of 18.1 (6.1) to 1.7 (1.2) at follow-up and all patients (100%) had scores <5. Similarly, the mean (SD) regurgitation subdomain decreased from a baseline of 13.2 (4.7) to 2 (1.6) at follow-up and all patients (100%) had scores <5. Patient satisfaction was achieved in 96.4% of patients with no PPI use required in 93% of patients (P < .001); only one patient required PPIs for persistent GERD symptoms. No cases of reoperation or esophageal dilatation were performed. Minor intraoperative AEs occurred in seven patients (i.e., neck emphysema). Conclusion: RefluxStop provides excellent safety and effectiveness outcomes for GERD treatment. Dysphagia completely resolved (0%) with 88.6% improvement in median GERD-HRQL score and satisfaction achieved in 96.4% of patients. These promising results reproduced the outcomes noted in the RefluxStop CE trial in real-world settings.

Improving treatment of people with gastro-esophageal reflux disease refractory to proton pump inhibitors

Proton pump inhibitors (PPIs) are the main treatment recommended and used for gastro-esophageal reflux disease (GERD). However, they fail to control symptoms in a substantial proportion of patients who have PPI-refractory GERD, which is defined as persistent symptoms attributable to objective findings of gastro-esophageal reflux. There remains a lack of dedicated guidelines to direct the management of these patients, some of whom could benefit greatly from surgical treatment. Too often patients remain long-term on ineffective treatment or stop treatment with lack of active review often resulting in their dissatisfaction going unnoticed. Also, concerns over efficacy and side effects of surgical procedures can be off-putting for both patients and physicians. It has been suggested that response to PPIs is predictive of surgical outcome. In this Perspective article we instead recommend that the key determinant should be whether symptoms are caused by GERD. We also discuss the traditional and newer surgical treatment options for people with PPI-refractory GERD.

IL-8, TNF-α, and IL-17 in the Development of Erosive Esophagitis and Symptom Perception in Gastroesophageal Reflux Disease (GERD)

Background: The diverse clinical characteristics of erosive esophagitis (EE) and symptom perception in patients with gastroesophageal reflux disease (GERD) remain a major challenge in understanding their underlying pathogenesis. This study aimed to investigate the association between the levels of IL-8, TNF-α, and IL-17 in serum and the presence of erosive esophagitis and symptoms related to GERD. Method: We enrolled 65 subjects presenting with GERD symptoms. Based on the findings of upper endoscopy, the subjects were categorized into two groups: (1) erosive esophagitis (EE LA grades B-D) and (2) non-erosive esophagitis (normal-EE LA grade A). Symptom perception was assessed via GERD questionnaire (GERD-Q) and the frequency scale for the symptoms of GERD (FSSG). The enzyme-linked immunosorbent assay (ELISA) method was used to analyze serum levels of IL-8, TNF-α, and IL-17. Analysis of cytokine levels between different symptoms severity was performed using the Kruskal-Wallis H test. Results: Median serum IL-8 levels were significantly higher in the erosive esophagitis group compared to those with non-erosive esophagitis (20.2 (IQR 16.9-32.2) vs. 17.7 (IQR 15.2-19.6), p < 0.05). The study found a significant association between IL-8 levels and the presence of globus symptoms (median IL8 level 46.961 (38.622-92.644) in subjects with globus vs. 18.06 (16.68-20.49) in those without globus; p < 0.05). Similarly, TNF-α levels were associated with the frequency of regurgitation symptoms (H index = 10.748; dr = 3; p < 0.05). We observed a significant correlation between IL-17 levels and the frequency of heartburn and early satiety symptoms. Conclusions: IL-8 may play a role in the development of mucosal erosion in GERD. IL-8, TNF- α, and IL-17 might be involved in the development of globus symptoms, the frequency of regurgitation, and the frequency of heartburn and early satiety, respectively. The diverse symptom phenotypes observed in patients with GERD symptoms may be mediated by distinct profiles of proinflammatory cytokines.

Symptoms, the GerdQ score and patients' characteristics do not predict gastroesophageal reflux disease in patients with proton-pump-inhibitor-refractory reflux symptoms-results from a large prospective database

Background

The number of patients with proton pump inhibitor (PPI)-refractory reflux symptoms is underestimated since many patients resign after an unsuccessful therapy attempt. Thus, it would be useful having a non-invasive tool that can help identify true gastroesophageal reflux disease (GERD) patients in order to manage them early and properly. The GerdQ is a validated tool developed for this purpose but its applicability in PPI-refractory patients has not yet been investigated. Our aim was to investigate if reflux symptoms per se, the GerdQ and patients characteristics are suitable for non-invasive diagnosis of GERD in patients with PPI refractory reflux symptoms.

Methods

A total of 500 patients from a prospectively recorded data base with PPI-refractory reflux symptoms were retrospectively analyzed. All patients received comprehensive diagnostic workup including EGD, pH-impedance measurement and manometry. GERD was diagnosed according to the recent Lyon consensus.

Results

Of all patients enrolled in the study, 280 (56%) finally fulfilled the criteria for objectively verified GERD according to the Lyon consensus. There were no significant differences in age and gender between the patients with and without GERD, whereas the body mass index was significantly higher in the group with verified GERD, but the discriminative value was low (Welch-Test, p < .001, Cohen's d = 0.39). Furthermore, there were no significant differences in the GerdQ values between the two groups. A GerdQ cutoff value ≥ 9 resulted in a sensitivity of 43% and specificity of 57% with a positive predictive value of 56% and a negative predictive value of 44%.

Conclusion

Based on our study, neither symptoms and the GerdQ score nor patients' characteristics are appropriate tools to distinguish between GERD and other causes for reflux symptoms in patients with PPI-refractory reflux symptoms.

Study of Acid-related Disorders: Real-world Physician and Patient Perspectives on Burden of Helicobacter pylori Infection

Background and Aims

Helicobacter pylori eradication rates have declined as antibiotic resistance rates have increased. In addition, adherence to treatment guidelines is suboptimal. It is therefore important that contemporary, real-world evidence of diagnostic and treatment patterns is explored and compared with evidence-based guidelines. The Study of Acid-Related Disorders investigated unmet needs among patients with H pylori infection and past or current dyspepsia.

Methods

Gastroenterologists (GIs) and family physicians (FPs) or general practitioners (GPs) treating patients with H pylori infection and past or current dyspepsia completed a physician survey and invited patients to complete a patient survey; data were also extracted from the medical records of enrolled patients.

Results

Two hundred fifty-one physicians and 77 patients were enrolled. A total of 19.5% of patients were diagnosed by serology, whereas the urea breath test was used by 6.5% of GIs and 50.0% of FPs or GPs. A total of 68.6% of GIs and 79.8% of FPs or GPs selected clarithromycin, amoxicillin, and proton pump inhibitor triple therapy as their ideal first-line treatment. Physicians reported that 52.9% of patients experienced dyspepsia daily. A total of 46.8% of patients believed that complete resolution of dyspepsia would indicate effective treatment. As their treatment goal, 69.3% of physicians selected improvement in overall symptoms, whereas 92.2% of patients specified improvement in dyspepsia. Only 28.7% of physicians were satisfied with current treatment options. A total of 59.7% of patients took all of their prescribed medicine(s). A total of 59.7% of patients would prefer to take fewer pills; 45.5% would prefer convenience packs.

Conclusion

This study reveals a lack of adherence to current H pylori guidelines for diagnosis, testing, and treatment. New treatment options that are more efficacious and simpler for patients to adhere to are needed.

Pathophysiology of gastroesophageal reflux disease-which factors are important?

Background

Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease.

Methods

For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI).

Results

In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m² (range, 20-45 kg/m²); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%.

Conclusions

In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.

Heartburn sensation in nonerosive reflux disease: pattern of superficial sensory nerves expressing TRPV1 and epithelial cells expressing ASIC3 receptors

The underlying causes of heartburn, characteristic symptom of gastroesophageal reflux disease (GERD), remain incompletely understood. Superficial afferent innervation of the esophageal mucosa in nonerosive reflux disease (NERD) may drive nociceptive reflux perception, but its acid-sensing role has not yet been established. Transient receptor potential vanilloid subfamily member-1 (TRPV1), transient receptor potential melastatin 8 (TRPM8), and acid-sensing ion channel 3 (ASIC3) are regulators of sensory nerve activity and could be important reflux-sensing receptors within the esophageal mucosa. We characterized TRPV1, TRPM8, and ASIC3 expression in esophageal mucosa of patients with GERD. We studied 10 patients with NERD, 10 with erosive reflux disease (ERD), 7 with functional heartburn (FH), and 8 with Barrett's esophagus (BE). Biopsies obtained from the distal esophageal mucosa were costained with TRPV1, TRPM8, or ASIC3, and CGRP, CD45, or E-cadherin. RNA expression of TRPV1, TRPM8, and ASIC3 was assessed using qPCR. Patients with NERD had significantly increased expression of TRPV1 on superficial sensory nerves compared with ERD (P = 0.028) or BE (P = 0.017). Deep intrapapillary nerve endings did not express TRPV1 in all phenotypes studied. ASIC3 was exclusively expressed on epithelial cells most significantly in patients with NERD and ERD (P ≤0.0001). TRPM8 was expressed on submucosal CD45+ leukocytes. Superficial localization of TRPV1-immunoreactive nerves in NERD, and increased ASIC3 coexpression on epithelial cells in NERD and ERD, suggests a mechanism for heartburn sensation. Esophageal epithelial cells may play a sensory role in acid reflux perception and act interdependently with TRPV1-expressing mucosal nerves to augment hypersensitivity in patients with NERD, raising the enticing possibility of topical antagonists for these ion channels as a therapeutic option.NEW & NOTEWORTHY We demonstrate for the first time that increased pain perception in patients with nonerosive reflux disease likely results from expression of acid-sensitive channels on superficial mucosal afferents and esophageal epithelial cells, raising the potential for topical therapy.

[Conservative Therapy of Reflux Disease and its Limits]

Gastrooesophageal reflux disease (GORD) is common. Proton pump inhibitors (PPI) are regarded as first line therapy for all clinical manifestations. However, their efficacy is inadequate for at least 30% of patients and they are occasionally poorly tolerated. Moreover, some patients would prefer an alternative therapy. Alginate cause mechanical reflux inhibition by forming a gelatinous layer in the so-called acid pocket, an acid reservoir that forms on the surface of the chyme in the gastric corpus immediately after food intake. They may be used an alternative to treat the symptoms of uncomplicated GORD and as an add-on to PPIs if these do not improve symptoms adequately. If the reflux symptoms persist or if reflux oesophagitis does not heal, differentiated diagnostic testing must be performed, using endoscopy and functional analysis. Extraoesophageal manifestations of GORD include cough, compulsive clearing of the throat, problems with the voice and globus sensation. These often do not respond to antireflux therapy. Recent data indicate that these are complex hypersensitivity syndromes and that reflux is only one of several possible triggers.

Washed microbiota transplantation reduces proton pump inhibitor dependency in nonerosive reflux disease

BACKGROUND

The pathogenesis of gastroesophageal reflux disease (GERD) is closely associated with the intestinal bacteria composition and their metabolites.

AIM

To investigate whether washed microbiota transplantation (WMT) improves symptoms of nonerosive reflux disease (NERD) with proton pump inhibitor (PPI) dependency.

METHODS

Patients with recurrent NERD and PPI dependency at the First Affiliated Hospital of Guangdong Pharmaceutical University from 2017 to 2018 were included and divided into a WMT or PPI group treated with PPI with/without WMT. The endpoint was NERD symptom frequency evaluated 1 mo after WMT using reflux disease questionnaire (RDQ) and GERD questionnaire (GERDQ) scores, remission time, PPI dose, and the examination of intestinal mucosal barrier function.

RESULTS

In the WMT (n = 15) and PPI (n = 12) groups, the total remission rate at 1 mo after treatment was 93.3% vs 41.7%. Compared with the PPI group, the WMT group showed better results in GERDQ (P = 0.004) and RDQ (P = 0.003) and in remission months (8 vs 2, P = 0.002). The PPI dose was reduced to some extent for 80% of patients in the WMT group and 33.3% in the PPI group. In 24 patients, intestinal mucosal barrier function was examined before treatment, and changes in the degree of damage were observed in 13 of these patients after treatment. Only one of the 15 patients had minor side effects, including a mushy stool two or three times a day, which resolved on their own after 1 wk.

CONCLUSION

This study is the first to demonstrate that WMT may be safe and effective for relieving NERD symptoms and reducing PPI dependency and recurrence.

Short-term outcome after robot-assisted hiatal hernia and anti-reflux surgery-is there a benefit for the patient?

PURPOSE

The robotic system was introduced to overcome the technical limitations of conventional laparoscopy. For complex oncological operations, it appears to offer further advantages. With regard to hiatal hernia repair, its role has yet to be determined.

METHODS

All consecutive patients who received elective laparoscopic or robot-assisted hiatal hernia repair at a single institution between January 2016 and July 2020 were retrospectively evaluated. We compared both techniques with particular focus on their short-term outcome. A propensity score-matched comparison considering clinical and surgical covariates was also performed between the two groups.

RESULTS

140 patients were included, and 55 (39.3%) underwent a robot-assisted procedure. The baseline demographics and the frequency of previous abdominal operations were comparable for both groups. The size of the hiatal hernia did not differ significantly between the groups (p = 0.06). The mean operative time was significantly longer for the robot-assisted procedure (149 vs. 125 min; p < 0.01) but decreased markedly during the study period. By contrast, no significant differences were observed in terms of conversion rate (p = 1.0) and blood loss (p = 0.25). Likewise, the postoperative morbidity was comparable for both groups (10.9 vs. 12.9; p = 0.79). The hospital length of stay was not significantly different between the laparoscopic and robotic group (4.0 vs. 3.6 days; p = 0.2). After propensity score-matching, 48 patients were identified for each group. Except for the operative time, no other significant differences were found. Thus, the results of the univariate analysis were confirmed.

CONCLUSION

Our initial results failed to demonstrate a clear advantage of the robotic technique in patients with refractory gastroesophageal reflux disease and/or symptomatic hiatal hernias.

Mucosal pathogenesis in gastro-esophageal reflux disease

BACKGROUND

Despite gastro-esophageal reflux disease affecting up to 20% of Western populations, relatively little is known about the molecular mechanisms underlying its most troublesome symptom: heartburn. Recent findings have unveiled the role of components of the esophageal mucosa in the pathogenesis of GERD including sensory nociceptive nerves and inflammatory mediators. Erosive esophagitis was long believed to develop as a result of acid injury at the esophageal lumen, but novel concepts suggest the generation of reflux-induced esophageal injury as a result of cytokine-mediated inflammation. Moreover, the localization and characterization of mucosal afferent nerves vary between GERD phenotypes and could explain the heterogeneity of symptom perception between patients who experience similar levels of acid reflux.

PURPOSE

The purpose of this review is to consider the crosstalk of different factors of the esophageal mucosa in the pathogenesis of GERD, with a particular focus on mucosal innervation and molecular basis of acid-induced cytokine response. We discuss the current understanding of the mucosal response to acid injury, the nociceptive role of acid-sensitive receptors expressed in the esophageal mucosa, and the role of esophageal epithelial cells in initiating the onset of erosive esophagitis.

Duration of adhesion of swallowed alginates to distal oesophageal mucosa: implications for topical therapy of oesophageal diseases

BACKGROUND

We have previously shown, ex vivo, that alginate solutions can have a topical protective effect on oesophageal mucosal biopsies exposed to simulated gastric juice. Oesophageal mucosal impedance can measure the duration of mucosal adherence of ionic solutions since the impedance drops when the solution is present, and rises to baseline as the solution clears.

AIM

To investigate the in vivo duration of adhesion of swallowed alginate solution to distal oesophageal mucosa.

METHODS

We studied 20 healthy volunteers and 10 patients with heartburn. A pH-impedance catheter was inserted, and baseline distal channel oesophageal impedance measured. Healthy volunteers received 10 mL of either sodium alginate (Gaviscon Advance), Gaviscon placebo (no alginate) or viscous slurry (saline mixed with sucralose), given in a randomised, single-blinded order over three visits. Patients received either sodium alginate or placebo on two visits. Initial impedance drop was measured, then 1-minute mean impedance was measured each minute until ≥75% recovery to baseline.

RESULTS

In healthy volunteers, sodium alginate adhered to the oesophageal mucosa for longer than placebo or viscous slurry (10.4 [8.7] minutes vs 1.1 [1.6] vs 3.6 [4.0], P < 0.01). In patients, sodium alginate adhered to the oesophageal mucosa for longer than placebo (9.0 (5.4) vs 3.7 (4.1), P < 0.01).

CONCLUSIONS

Sodium alginate solution adhered to the oesophageal mucosa for significantly longer than placebo or viscous slurry. This demonstrates that alginates could confer a protective benefit due to mucoadhesion and can be a basis for further development of topical protectants and for topical drug delivery in oesophageal disease.

Efficacy of vonoprazan for initial and maintenance therapy in reflux esophagitis, nonerosive esophagitis, and proton pump inhibitor-resistant gastroesophageal reflux disease

Proton pump inhibitors (PPIs) have been the first line treatment for gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the efficacy of vonoprazan (VPZ), a potassium-competitive acid blocker for reflux esophagitis (RE), nonerosive reflux disease (NERD), and PPI-resistant GERD patients.An open-label, single-center, observational study in our hospital was performed from August 2016 to August 2017. All patients diagnosed with GERD were asked to self-report a questionnaire of frequency scale for the symptoms of GERD (FSSG) and rate their degree of satisfaction with the treatment of GERD during outpatient visit. A total of 200 (RE 47, NERD 49, PPI-resistant GERD 104) patients were included in the present study. The primary endpoint was the change of FSSG and the proportion of degree of satisfaction with the treatment at the end of the initial therapy. A percentage of improvement (improvement rate) and resolution (resolution rate) at the end of the initial therapy were evaluated. Secondary endpoint included the proportion of patients with symptomatic relapse in the 24-week maintenance phase.FSSG and the degree of satisfaction were significantly improved after the initial therapy in every group. Improvement and resolution rate after the initial therapy were 83.0% and 67.0% in RE, 66.7% and 60.4% in NERD, and 76.0% and 60.4% in PPI-resistant group. There was no significance between after the initial therapy and 24 weeks in improvement and resolution rate. Thirty-two of the total 48 patients did not take VPZ at 24 weeks. Total FSSG score in each group was 1.67 ± 1.97, 2.71 ± 4.91, and 4.0 ± 4.93. The nonrelapse rate at 24 weeks in each group was 66.7%, 60.0%, and 50.0%. The resolution rate at 24 weeks in each group was 38.9%, 45.0%, and 30.0%.The VPZ therapy is effective for initial and maintenance therapy and improves heartburn and patient's satisfaction significantly in all 3 groups. Among patients who stopped taking VPZ during the maintenance period, 42.0% of RE and NERD group and 30% of PPI-resistant group experience complete remission from GERD at 24 weeks by introduction of VPZ.

Sustained proton pump inhibitor deprescribing among dyspeptic patients in general practice: a return to self-management through a programme of education and alginate rescue therapy. A prospective interventional study

Background

Dyspepsia guidelines recommend that patients treated with proton pump inhibitors (PPIs) should step down to the lowest effective dose or return to self-care, but rebound hyperacidity can make this difficult. Many patients continue on PPIs in the long term, which may lead to safety and financial implications.

Aim

To determine if a nurse-led educational support programme and rescue therapy for rebound symptoms can help patients achieve a sustained reduction in PPI use.

Design & setting

A prospective interventional study was conducted at 26 surgeries across the UK.

Method

Adult patients, treated with PPIs for ≥2 consecutive months with an active repeat prescription, were invited to a 20-minute dyspepsia clinic appointment with a trained nurse adviser. An action plan to reduce and/or stop their PPI usage was agreed and alginate supplied for the self-management of rebound symptoms. After 12 months, PPI status was reviewed and prescribing cost savings calculated.

Results

After 12 months, 75.1% of 6249 eligible patients stepped down or off PPIs (35.3% stepped off; 5.0% stepped down then off; 34.8% stepped down only), while 8.7% of patients had reverted to their original PPI dose. PPI prescriptions fell from 89 915 to 45 880 and alginate prescriptions increased from 2405 to 6670. An average of 1.7 bottles (500 ml each) of alginate were used per patient who stepped down or off. Estimated annual cost-saving on prescriptions was £31 716.30.

Conclusion

A programme of education and short-term rebound symptom management helped the majority of patients to successfully step down or off PPIs, significantly reducing the potential risks associated with chronic therapy.

[Functional dyspepsia in primary care: therapeutic variety or helplessness?]

BACKGROUND

About 5% of all GP consultations are made for symptoms of functional dyspepsia. The definition of functional dyspepsia is in a state of flux, pathophysiology is poorly understood, and current diagnostic and therapeutic algorithms are not available.

AIM

Evaluation of the frequency and the practical procedure in the diagnosis and therapy of functional dyspepsia in German GP surgeries.

METHOD

Family physicians working in Germany (general practitioners, primary care internists) were contacted via postal survey. The frequency of patients with functional dyspepsia per week, the symptom spectrum complained of and the therapy strategy were inquired.

RESULTS

Data from 322 doctors from all over Germany could be evaluated. The majority of physicians cared for 6-10 RMS patients per week (44.1%). The most common symptoms reported by patients were postprandial fullness (81.7%), epigastric pain or burning (77.3%) and regurgitation (75.0%). Heartburn (50.0%), nausea/vomiting (42.5%) and premature satiety (15.8%) were reported less frequently. The most commonly prescribed drugs were phytotherapeutics (88.2%), proton-pump inhibitors (PPI, 73.6%) and prokinetics (61.5%). The frequency of prescribing antacids, digestive enzymes of the stomach and pancreas was 10-20%. There was a trend towards symptom-dependent differential therapy: phytotherapeutics and prokinetics in postprandial fullness and premature satiety, PPI in epigastric pain/burning. The treatment failure rate was estimated at 21-40%. For further diagnostics patients are often referred to gastroenterologists and psychotherapists.

CONCLUSION

Functional dyspepsia is common in primary care practice. Current recommendations for diagnosis and differential therapy are often not implemented. The rate of treatment failure is considerable.

[Surgical and interventional procedures for reflux therapy : Endoscopic or laparoscopic?]

An optimal functioning of the gastroesophageal antireflux barrier depends on an anatomical overlapping of the lower esophageal sphincter and the crural diaphragm. Restoration of this situation is currently only possible by antireflux interventions combined with hiatoplasty and necessitates a laparoscopic approach. Newer alternative techniques to the generally accepted fundoplication are laparoscopic implantation of the LINX® device or the EndoStim® system and various endoscopic antireflux procedures, such as radiofrequency energy treatment, plication and implantation techniques aimed at augmentation of the gastroesophageal valve. Endoscopic techniques are becoming established more and more between pharmaceutical and surgical therapy instead of replacing them.